NoAbridged version of article Milne E, Johnson SE, Waters GM et al (2018) The mother-infant bond: a systematic review of research that includes mothers’ subjective experience of the relationship. Community Practitioner. Accepted for publication

Johnson, Sally E.

Milne, Elizabeth

Small, Neil A.

Waters, Gillian M.

Milne, Elizabeth J.M.

Bradford Scholars

45 COMMUNITY PRACTITIONER  |  FEBRUARY 2018UNDERSTANDING THE  MOTHER-INFANT BONDWhile the importance of the parent-infant relationship is emphasised in research and in policy, for example in the Department of Health’s Healthy Child Programme, it is not clear how mothers actually experience the relationship, how mothers see their infant’s internal world, or if they experience companionship with their infants.The infant is a sensitive, social being (Trevarthen, 2015), capable from birth of having complex and reciprocal interactions with others (Trevarthen, 1998). The majority of infant mental health issues are associated with relationship disturbances (Zeanah et al, 2000); therefore, much research has investigated parental behaviours that benefit the parent-infant relationship.‘Mind-mindedness’ appears to be a powerful factor in the parent-infant relationship. The concept of mind-mindedness refers to the caregiver’s ‘proclivity to treat her infant as an individual with a mind, rather than merely as a creature with needs that must be satisfied’ (Meins et al, 2001) (see What is mind-mindedness? on page 46).In infancy, mind-mindedness predicts security of attachment with caregivers, and children’s later ability to infer mental states to self and others (Meins et al, 2013). It also predicts child outcomes in areas of cognition, linguistics and play (Meins, 2013). Mind-mindedness, therefore, with its appropriate sense-making of the infant’s internal world, may enhance the parent’s ability to be a companion to their infant.Companionship is a necessity for the infant, benefiting cognitive and social development, including language, culture, memories, and tying people together through affection, mutual joy and discovery (Reddy, 2010). Understanding mothers’ subjective experiences of their relationships with their infant should inform the development of interventions to support the mother-infant relationship. EMOTIONS AND EXPECTATIONSParents tended to describe pleasure in the relationship by using global terms of loving the baby (Zeanah et al, 1990). Pleasures included pride in motherhood, some caregiving tasks and successful meeting of the infant’s needs, and holding and close contact with the baby (O’Brien and Lynch, 2011; Horowitz and Damato, 1999; Blank et al, 1995).Anger, frustration, confusion, anxiety and stress were common maternal experiences (Parfitt and Ayers, 2012; O’Brien and Lynch, 2011; Bell et al, 2007; Limbo and Pridham, 2007; Murphy, 2007; Horowitz and Damato, 1999; Olsson et al, 1998).  ABRIDGED VERSION Elizabeth Milne, Sally Johnson, Gill Waters and Neil Small explored mothers’ interpretations of their infants’ behaviour, and the impact of ‘mind-mindedness’, or treating a baby as an individual with a mind. Researchers at the University  of Bradford undertook a systematic review of research to answer the question: how do mothers describe the mother-infant relationship?   From 5688 possible  articles, twelve studies  met inclusion criteria.  It was considered important  to understand mothers’ subjective experiences  to support the mother- infant relationship.   Studies demonstrated that mothers often had unrealistic expectations of infants.  Parents often perceived their infant as coercive and manipulative, or understood the infant’s response as personal and negative feedback.  There was little evidence of mothers seeing mutuality or companionship in their relationship with their infants.  Health visitors can make valuable interventions to support mothers in making appropriate meaning of their baby’s mind.RESEARCH  SUMMARYCO UNITY PRACTITIONER | SEPTEMBER 2 18RESEARCHMOST MOTHERS DID NOT CONVEY A SENSE OF MUTUALITY OR COMPANIONSHIP  WITH THEIR INFANTSRESEARCH46 COMMUNITY PRACTITIONER  |  FEBRUARY 2018The studies demonstrated that mothers often had unrealistic expectations of infants: for example, the wish  for babies to be ‘easy, calm and well-behaved’ (Staneva and Wittkowski, 2013) was evident.One study presented a lack of parental knowledge  regarding infant capacity, with over half of the parents agreeing antenatally that ‘babies under six weeks old just feed, sleep, cry or fill their nappies’ (Delight et al, 1991). Importantly, parents who had expected infant responsiveness antenatally were more likely to observe it postnatally. MAKING SENSE OF INFANTSWhile there was evidence of some parents having appropriate perceptions of their infant’s internal world (Parfitt and Ayers, 2012; Limbo and Pridham, 2007; Murphy, 2007), a strong theme was of parents perceiving the infant as coercive and manipulative, or taking the infant’s response as personal and negative feedback (Porter and Ispa, 2013; Parfitt and Ayers, 2012; O’Brien and Lynch, 2011; Limbo and Pridham, 2007; Murphy, 2007; Zeanah et al, 1990). Lack of attuned understanding could be connected to the parent experiencing the child as frustrating or angering (Murphy, 2007) and parents perceiving themselves in a ‘battle’ with their child (Limbo and Pridham, 2007; Murphy, 2007).There were also examples of health visitors appearing to perpetuate the image of the infant as coercive and demanding (Murphy, 2007).Parents’ emotional and mental states were related to the sense a parent makes of their infant. Parfitt and Ayers (2012) found that angry parents, or those who were depressed or anxious, were more likely to make comments suggesting a lack of understanding of their infants. Meeting their baby’s needs could give mothers a sense of success (Parfitt and Ayers, 2012; Bell et al, 2007; Murphy, 2007; Blank et al, 1995). In contrast, when the baby was unhappy, struggling or wanted to do something different from the mother, mothers tended to interpret it personally, as if the infant was communicating how they felt about the mother (Porter and Ispa, 2013; Parfitt and Ayers, 2012; Bell et al, 2007; Murphy, 2007; Blank et al, 1995), leading to feelings of failure or anger (O’Brien and Lynch, 2011).However, appropriate meaning-making could dissipate frustration and personalisation of problems (Murphy, 2007), and maternal recognition of the infant’s internal world could result in the mother adjusting their behaviours to meet their infant’s needs (O’Brien and Lynch, 2011).VALUING MUTUALITY For some mothers, mutuality was something to look forward to as the infant got older (Horowitz and Damato, 1999; Blank et al, 1995). However, some parents appeared to particularly value the sense of their infant’s agency and mutuality in their relationship. The infant’s smile was identified as an opening to CO UNITY PRACTITIONER | SEPTEMBER 2 1847 COMMUNITY PRACTITIONER  |  SEPTEMBER 2018 WHAT IS MIND-MINDEDNESS? Mind-mindedness can benefit child outcomes in the following ways:Security of attachmentAbility to  infer mental states in self and othersCognitionLinguisticsPlayCompanionshipAffection, mutual joyGood mental healthMeins et al, 2013; Meins, 2013; Reddy, 2010RESEARCH46 COMMUNITY PRACTITIONER  |  FEBRUARY 2018To view references and the full version of this paper, entitled The mother-infant bond: a systematic review of research that includes mothers’ subjective experience of the relationship , go to bit.ly/CP_research_milnea reciprocal relationship for some parents (Zeanah et al, 1990), inviting shared pleasure in the relationship (Horowitz and Damato, 1999) and humanising the infant (Parfitt and Ayers, 2012). However, most mothers did not convey a sense of mutuality or companionship in their relationships with their infants. While the social development of the baby was found to be of particular importance to parents (Parfitt and Ayers, 2012), parents recognising that the infant was responsive did not equate to parents perceiving their infant as relationally active ( Delight et al, 1991; Zeanah et al, 1990). Recognising that the infant responds to a stimulus does not require recognition of the internal world of the infant, or any sense of mutuality or companionship in the relationship. SUMMARY Companionship and/or connection was not often described by mothers. Where data were collated by means of observing mothers’ interactions with peers and professionals, any reference to the mother-infant relationship was largely absent. It may be mothers do not recognise their infants as relational or themselves as in a relationship with their infants (see Research findings, above). Mothers’ perceptions of their infants as coercive and demanding were associated with a sense of the child as frustrating or angering (Murphy, 2007) and being in conflict  with the child. Experts, including health visitors, were also  seen to perpetuate the story of the coercive and demanding  baby (Murphy, 2007).However, it appears that appropriate meaning-making of the infant could dissipate frustration, and reduce the tendency to personalise the infant’s distressed behaviour as negative feedback about the mother (Murphy, 2007).Maternal recognition of the infant’s internal world could result in the mother adjusting her behaviours to meet the infant’s needs (O’Brien and Lynch, 2011). Pleasure from mutuality may be valuable, given how anxiety-provoking and negative early parenthood experiences were found to be (Parfitt and Ayers, 2012; Bell et al, 2007; Horowitz and Damato, 1999; Olsson et al, 1998; Zeanah et al, 1990). It is apparent that there has been a lack of in-depth investigation into mothers’ experiences of their mother-infant relationships, and how they perceive their infant’s relational capacity and internal worlds. It appears that parents see what they expect to see and are veiled from their infant’s capacity if it is not consistent with their expectations (Delight et al, 1991).Based on this review, there are grounds to support interventions from health professionals – including health visitors, – which seek to change the way mothers perceive their infants (see Recommendations for practice, below).CONCLUSIONIf health visitors are to support the transition to parenthood and the parent-infant relationship consistent with the Healthy Child Programme, and as parents have been found to perceive what they expect to perceive, interventions aimed at supporting mothers to make appropriate meaning of their baby’s minds may be valuable. Such interventions have the potential to alleviate stress, facilitate sensitive and attuned parenting, and enable a sense of companionship. Research should focus on how to make these conversations effective and practicable.  Elizabeth Milne is a PhD student at the University of   Bradford and clinical lead perinatal mental health,   Bradford District Care Trust; Dr Sally Johnson is senior   lecturer in psychology, Dr Gill Waters is lecturer in   psychology, and Professor Neil Small is professor of   health studies, all at the University of Bradford. 47 COMMUNITY PRACTITIONER  |  SEPTEMBER 2018RECOMMENDATIONS FOR PRACTICE  Health visitors may be well placed to emphasise infants’ limited  self-control and inability to manipulate their parents. This might be  reinforced by providing information on the infants’ neurodevelopment.  They should focus on promoting the relational capacity of infants  to mothers.   Interventions by health visitors to improve mothers’ knowledge of  child development at every contact may assist mothers in making  more appropriate – and thus stress-reducing – inferences about their  child and invite mind-mindedness.RESEARCH FINDINGSThe study suggested  that mothers:   Often have inappropriate expectations of their infants’ behaviour   Demonstrate non-responsive and non-attuned behaviour with limited understanding of their infant’s internal world  Perceive their infants as coercive and demanding and/or their behaviour as personal and negative feedback. 

Understanding the mother-infant bond

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Understanding the mother-infant bond

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